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Table 3 Characteristics of included studies

From: What are the strategies for implementing primary care models in maternity? A systematic review on midwifery units

N Author, Year Country Study aims Design Participants Setting and data collected Findings Quality
1a Cheung NF et al. 2009 [19] China To describe the preparations for setting up a midwife-led normal birth unit which was based on literature and practice review Action research with a five steps cycle plus a literature review 8 midwifery team leaders
5 researchers
A highly medicalised maternity department in a Chinese hospital with annual birth rate of over a 3000. The MU was allocated two birthing rooms. The researchers analysed data from meetings, field notes and midwifery training course. The findings are divided into seven sections: definition, negotiations, accommodation, specific practices, the philosophy of the homely birthplace, policy development, and developing local solutions for local aspirations. 8
1b Mander R et al. 2009  China To explore issues arising during preliminary stages of the action research project to consider the feasibility and the effects of a MU on midwives and women. Action research using a qualitative descriptive approach Non-defined number of stakeholders including midwifery staff, managers, university staff and researchers. (same setting as above)
Data were collected at meetings, by non-participant observation and by face-to-face semi-structured interviews.
MU care may be feasible after the analysis of the early stages of implementation. 8
2 Mackey MC et al.1991 [20] US To report on how the idea of birthing room was initiated by nurses and the 8 strategies that led to the implementation of it. Structured interviews 4 registered nurses with Master’s degree Four private hospitals located in the Chicago area. One-hour in-depth interviews. Eight strategies to be used jointly to open new birthing rooms by nurses’ midwives 7
3 Moudi Z et al. 2013 Iran To assess 10 years of experience of the first Safe Delivery Posts (SDPs) established in Zahedan, Iran and to examine the reasons why women chose to give birth there. A mixed-methods research 19 service users in the postnatal period The two SDPs in Zahedan, the most populous city in the province. Women were selected from two Safe Delivery Posts in Zahedan city in southeast Iran. Implementing a model of midwifery care that offers the benefits of modern medical care and meets the needs of the local population is feasible and sustainable. This model of care reduces the cost of giving birth and ensures equitable access to care among vulnerable groups in Zahedan. 9
4a Pereira AL and Moura MA 2009 [21] Brazil To identify the determinants of the process of implementing the Birth Center and analyse the influence that hegemonic and counter-hegemonic groups have on that process Dialectic qualitative research 4 commissioners
11 technical administrative professionals
Casa de Parto in Rio de Janeiro. Individual semi-structured interviews. During the establishment process, conservative and transformative forces of the hegemonic childbirth care model clashed in the governmental and civil spheres. Legal and political dispute in the establishment process of the Casa de Parto highlighted the importance of organized social movements, especially the women’s movement. 7
4b Progianti JM et al. 2013 [22] Brazil To discuss how the Brazilian nurse midwives trained in the Japanese birthing centres helped to implement the FMU in Brazil. Socio-historical study with qualitative approach 1 Director of nursing
1 Nurse midwife
1 Physician
1 Former nursing director
Casa de Parto in Rio De Janeiro. Written and oral documents. Semi-structured interviews and report of the exchange experience. Data triangulation with policy and background documents. The exchange programme enabled the Brazilian midwives to implement the first MU in Rio de Janeiro and added a larger volume of capital to their professional habitus. 9
5 Reszel J et al. 2018 [23] Canada To obtain the perspectives of health care providers and managerial staff about the integration of the new FMUs one year after implementation Qualitative descriptive approach 24 amongst professionals (18) and managerial staff (6) Ontario where homebirth and birth in OU were the only two birth settings for women prior the implementation of the two FMUs. Data was collected via 4 focus groups and 1 interview. The collaborative approach for the planning and implementation of the MUs was a key factor in the successful integration and the positive experience of service users. 10
6 Walton et al. 2005 [24] England To explore organisational factors, midwives role, barriers and facilitators of the change process and training needs for midwives Action research Non-defined number of stakeholders including midwives, managers and medical staff. Inner London teaching hospital that take care of over 4400 women a year. Data from meetings, educational workshops, feedback forms and audit of the 2 birthing rooms The lack of support from medical staff, the conflicting priorities and the dominance of the medical model of care made the project not feasible and the team abandoned the idea of the MU after this pilot. 6
7 Walsh et al. 2018 [25] England To describe the configuration of midwifery units, both alongside & freestanding, and obstetric units in England National survey Heads of Midwifery in English Maternity Services National Health Service (NHS) in England. Descriptive statistics of AMUs, FMUs and OUs and their annual births/year in English Maternity Services Number of MUs and births in MUs in England increased after the publication of NICE guidelines (mostly AMUs). Significant difference in terms of utilisation of the MU and this suggest that some are underutilised. 10
8 Walsh et al. 2020 [14] England To identify factors influencing the provision, utilisation and sustainability of MUs in England Qualitative study 57 Obstetric, midwifery and neonatal clinical leaders, managers, service user representatives and commissioners 60 midwives 52 service users Setting England. Data collected: first, MU access and utilisation across England was mapped; second, local media coverage of the closure of free-standing midwifery units (FMUs) were analysed; third, case studies were undertaken in six sites to explore the barriers and facilitators that have an impact on the development of MUs; and fourth, by convening a stakeholder workshop. Most managers and clinicians did not regard their MU provision as being as important as their OU. The analysis illuminates how implementation of complex interventions in health services is influenced by a range of factors including the medicalisation of childbirth, perceived financial constraints, lack of leadership and institutional norms protecting the status quo. 10
9a McCourt et al. 2018 [26] England To investigate how AMUs are organised, staffed and managed, the experiences of women, and maternity staff including those who work in AMUs and in adjacent obstetric units. Some MUs were already established, other just recently being implemented. Organisational ethnography approach 35 managers and key stakeholders
54 professionals
47 service users
Case studies of 4 AMUs in England, selected for maximum variation based on geographical context, length of establishment, size of unit, leadership and physical design. Observations, semi-structured interviews and documentary review were conducted. Development of AMUs was often opportunistic. Key potential challenges included: boundary work and management; professional issues; developing appropriate staffing models and relationships; midwives’ skills and confidence; and information and access for women. 10
9b McCourt et al. 2014 [18] England (same as above) (same as above) (same as above) (same as above) Same as 9A but explored more in detail. 10